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Request for Graduate Leave of Absence

This form is to be used by graduate matriculated students only. Please complete this form and obtain the appropriate signatures before it is returned to the Registrars Office, room 217 HAN. This form is not an authorization for an official withdrawal of courses in progress. When you wish to resume your graduate studies, you must file a readmission application with the Admissions Office.
Please Note: A leave of absence for a specific period may be approved upon application to and approval of the Graduate Advisor and Divisional Dean. Sick leaves of absence are approved only for reasons documented disabling illness, maternity, military service, or other unusual circumstances. Leaves of absence extend the time limit allowed for your curriculum. The total time limit for completing all degree requirements is 4 years. Programs in Education, Nursing, Health Sciences, and Social Work the time limit is 5 years.
 

***Leaves of absence may be approved for a maximum of 2 semesters.

Name: __________________________________________________________________________
           Last                                   First                           Middle                                Maiden or Other

Address:_________________________________________________________________________
               Number and Street                              Apt #            City                  State                 Zip Code

ID# (Social Security #)_____/____/_____

Home Phone(_____)__________

Work Phone(_____)___________

Curriculum: ____________________________

Date of Matriculation: ______/_____/______

Are You Currently enrolled in Course work?

_____Yes     _____No

Students Signature ___________________________________
 

*****To Be Filled Out By Graduate Advisor And Divisional Dean*****

        A leave of absence has been granted to:

_________________________________________

For the period from: ______/_____ Through:______ /_______
                               Month       Year

                                                                Month        Year

Advisors Signature___________________

Department Signature__________________________

Divisional Deans Signature___________________________ Date ______/______/_______